Planes of Fascia

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A Description of the Planes ofFascia of the Human Body

With Special Reference to the Fascia of the

Abdomen, Pelvis and Perineum

By B. B. Gallaudet

Gallaudet held a position in the Department of Anatomy at Columbia Univer-sitys College of Physicians and Surgeons in New York. Columbia University

Press published this text in 1931. The copyright has since expired; therefore,

the book is now within the public domain. Triggerband is republishing this text

in electronic form.

Copyright 2008 Triggerband LLC.

Preface

This description is based on actual dissection by myself o

human bodies, equally divided between the sexes, during the

inclusive. This dissection was supplemented by work with th

bodies in the general dissecting room, during and before Also a number o f frozen sections (frontal, sagittal etc.) espe

abdomen, pelvis and perineum, were made but were not sa

These are the three regions the fascial planes (or fasciae) o

opinion inadequately described in our standard English an

books; and this inadequacy is the reason for my attempting to

different description.

As to the other regions of the body, viz., head and neck, t

tremities, although the fasciae of these are fairly well describe

text books, this description fails to make clear or to emphaplanes of fascia in one region of the body are directly continu

planes in all other regions. In other words the law of continui

is not stressed.

These proposed corrections will be made in the following

will be at first general, then systemic, and then regional. C

tions of the description will of course conform to the text of a

in English on anatomy.

B. B. G.


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General Considerations

The fascial planes or fasciae really constitute, in the non-dissected condition,

a sheet of connective tissue varying in thickness and density according to lo-

cality. This covers and invests all the so-called higher structures; i.e., muscles

and tendons, bursae, vessels, lymph nodes, nerves, viscera, ligaments, joints,

and even cartilage and bones, these last by close adhesion to perichondrium

and periosteum between the attachments of the muscles.

This plane of fascia, from a gross anatomical viewpoint, does not include con-

nective tissue which closely surrounds or belongs to, any of the higher struc-

tures above mentioned. Thus, the epimysium of muscle and tendon, the

epineurium of nerves, capsules of glands etc., are not to be regarded as parts

of this fascia, although of course more or less closely adherent to it. This ad-

herence is actually effected by innumerable minute trabeculae demonstrable

while the fascia is being dissected off. After this dissection the epimysium, the

epineurium etc., are intact. As to the vessels, the sheath of these is a deriva-

tive of the fascia but must not be confounded with the tunica adventitia (or ex-

terna) which is an integral element of vascular make-up.

Furthermore, for purposes of description, the following structures should also

be excluded from this common plane of fascia: (1) sheets of delicate areolar

tissue found in certain potential spaces, e.g., the retropharyngeal space; (2)

certain deposits of fatty tissue which lie deep to or between, secondary lami-

nae of the common plane, e.g., the buccal pad, the pad anterior to the tempo-

ral muscle, the orbital fat, irregular patches or masses situated close to

muscles and other deep structures, particularly in the neck and extremities;

(3) the subdural areolar tissue. These areolar and fatty structures are also con-

nected by trabeculae with the overlying fascia and, although well marked in

fat subjects, may occur in otherwise lean subjects.

This common plane of fascia will now be considered, first systemically, andthen regionally.

The Systemic Fasciae

There are grossly, two principle planes or sheets, each of w

sidered a system of fascia. Each system lies deep to or awa

other of those two surfaces of the body known respectively

surface and the serous surface.

Thus, the systems of fascia are (1) the subcutaneous syste

serous system. Although for the most part these systems afrom each other, portions of each are directly continuous o

This continuity occurs through the superior aperture of the t

openings (to be specified) in the abdominal wall and pelvis.

The Subcutaneous System

This fascia consists of two layers, the superficial and the de

careful dissection. These layers are adherent to each other

beculae.

The superficial subcutaneous layer. This is described as beitwo layers: (1) the superficial layer of the superficial fascia

layer of the superficial fascia.

(1) The superficial layer is the fatty layer. It contains most of

stitutes the main fatty tissue of the outer surface of the body

than an inch in thickness. This layer is also called the tela ad

niculus adiposus, and when thick may easily be split into

When thin it is almost impossible to separate it from the dee

cial fascia without tearing holes in both layers. However,

plane of cleavage between these layers which is made by

teries, veins, nerves, lymphatic vessels and nodes, some of t

mammary gland. Nevertheless, when the superficial layer oproperly dissected off, these structures are seen, each one, t

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a delicate film of tissue still connected with the deep layer, its connection with

the superficial layer having been severed during the dissection.

For this reason the statement that these structures run through one layer of su-

perficial fascia would seem at least more accurate than the usual statement

that these structures run between the two layers of the superficial fascia. It is,

of course, understood that these superficial vessels and nerves are branches

of deep vessels and nerves (see below) and must, therefore, pierce overlying

fascia (deep fascia and deep layer of superficial fascia) in order to reach thisinterfascial situation, while branches of these which are finally destined for the

skin, pierce the topmost fascial layer.

(2) The deep layer of the superficial fascia lies immediately over or on top of

the deep fascia, from which it may be distinguished, especially on the head,

neck and extremities, by the greater density of the latter. This deep layer of

the superficial fascia is a thin gray membrane which in well-conditioned sub-

jects is said to be dev oid of fat. In even moderately fatty subjects, however, it

does seem to have some fat of its own, even after a most careful removal of

the fatty superficial layer along the plane of the intervening vessels and nerves.

Although the adhesion between this layer and the deep fascia is close there arecertain lines or edges along which this adhesion is especially close. These

edges may be a sharp border of bone, the free edge of a tendon or the edge

formed by the splitting of a layer of deep fascia into two or more layers (see

below).

The deep subcutaneous layer. This is called simply the deep fascia of the re-

gion where situated, e.g., deep cervical fascia, deep perineal fascia, etc.

This fascia, although forming a continuous layer all over the body, varies in

density according to the region in which it is found. Thus it is most dense on

the extremities, less so on the head and neck, and even thin on the thorax,

abdomen and perineum, where it often appears to be more delicate than the

overlying deep layer of the superficial fascia.

This fascia covers (1) all the muscles (except the superfici

head and neck, and the palmaris brevis), (2) all the large blo

the large nerves, (4) the deep lymphatics and nodes, and (

Besides covering, it also invests these structures.

The term invest means that a layer of this fascia when trace

(e.g., vertically or transversely, etc.) on meeting any oneabove mentioned, splits into laminae which surround the s

reunite. This investment is grossly often called the sheath o

properly so as regards arteries and veins, but not to be c

epimysium and epineurium, (already spoken of) when, as

case, these are also called sheaths.

A layer of this fascia may a lso split to enclose a potential spa

of this fascia may meet several superimposed strata of othe

cles, viscera, etc.) in which case it splits into as many laye

essary to invest each stratum.

This investiture might be regarded as the phenomenon of spup more specifically under regions. Conversely, any two or

ers if traced away from the structures they have invested w

plane. This might be called the phenomenon of reunion.

This fascia also exhibits the phenomenon of very close adhe

edges previously referred to under deep layer of the superf

It is understood that while this adhesion along edges affects

cia, each may be separated from the other, and the deep fas

itself, by careful dissection (see regions).

Fusion may occur. A layer may be so closely adherent to an

over it or under it, as to form practically a single new layer.

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scalp and perineum.

The Subserous System

This is limited to the thoracic and abdominal cavities, and the surface is the

serous membrane lining these cavities and enveloping or covering the con-

tents of each. The thoracic serous membrane is the pleura (including in the

embryo the serous layer of the pericardium); and the abdominal serous mem-

brane is the peritoneum. That portion of each serous membrane which lines itsrespective cavity is called the parietal layer, e.g., parietal pleura, parietal peri-

toneum; while the portion which envelops the contents of such cavity is called

the visceral layer, e.g., visceral pleura, visceral peritoneum. Inasmuch as the

visceral and parietal layers, in each case, are continuous, they face each other

and form a closed sac with a potential space between often known as a cav-

ity, e.g., pleural or peritoneal cavity, which contains nothing and must not be

confounded with the thoracic or abdominal cavity respectively. There are two

pleural sacs and one peritoneal sac.

The subserous fascia, like the subcutaneous, has two layers, (1) the superfi-

cial subserous fascia which lies next to the pleura or peritoneum, and (2) the

deep subserous fascia.

The superficial subserous fascia. This, unlike the corresponding subcutaneous

fascia, cannot be split into regular layers. It contains the fat or is the fatty tis-

sue of the inner surface of the thorax and abdomen. Inasmuch as it follows or

lies next to pleura or peritoneum, like them it must and does have two por-

tions, the sub-visceral and the sub-parietal. The former are direct prolonga-

tions to the viscera of the latter.

The deep subserous fascia. This is a grayish fairly substantial membrane

greatly resembling certain portions of the deep subcutaneous fascia and shows

many, if not all, of its phenomena (see above). This layer lies deep to the pari-

etal portion of the superficial subserous layer and does not send any prolon-

gations onto the viscera with the exception of the prostate

serous fasciae will be further considered under regions.

Reconsidering the subserous fascia as a whole: this entire

completely divided by the diaphragm into two regions, intrat

abdominal.

In the thorax, the superficial subserous layer is called the su

areolar tissue) and the deep subserous layer is known asfascia.

In the abdomen the corresponding layers are called respec

toneal fascia (or areolar tissue) and the transversalis fascia

Regional Fasciae

Fasciae of the Abdomen

These are (1) subcutaneous and (2) subserous. The abdbounded by a wall. Part of this cavity is the pelvic cavity. The

cavity is made up of muscles, their tendons, and bones. T

lumbar vertebrae, sacrum, coccyx, ilium, ischium and pubis

the diaphragm above and behind, the levator ani and coc

cluding the sacro-coccygeus ant. and uro-genital diaphragm

issuing from the pelvis and the broad ventro and dorso-late

ing the quadratus lumborum. The levator ani and coccyge

muscles of the pelvic diaphragm, (q.v.), which structure thu

lates the extreme lower portions of the pelvic cavity, which

ischiorectal fossae (q.v.).

This wall is covered on its outer surface by the subcutaneo

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cia and on its inner surface by the subserous abdominal fascia. In other words,

the wall of the abdomen lies everywhere between these two planes of fascia.

It will be more convenient to call the first extra-abdominal and the other intra-

abdominal fascia.

The Extra-abdominal Fascia

This fascia covers those portions of the external oblique and latissimus dorsi

which form the outside layer of the abdominal wall. Furthermore, it covers boththe muscular part of these muscles as well as their tendons.

Traced upward this fascia becomes, i.e. is directly continuous with, the sub-

cutaneous (extrathoracic) thoracic fascia. The boundary line extends on each

side from the ensiform cartilage along the lower edges of the seventh to the

twelfth costal cartilages and then slightly upward to the spinous process of the

twelfth thoracic vertebra. Over the edges of the cartilages some degree of ad-

hesion is noticeable.

Traced downward, this fascia is directly continuous with, or becomes the sub-

cutaneous fascia of: (1) the lower extremity; (2) the scrotum (or labia majora)

and spermatic cord (genetic cord); (3) penis (or clitoris); and (4) perineum.

Traced backward, this fascia passes completely around the body from the linea

alba to the spinous processes of the vertebrae, from the twelfth thoracic to tip

of coccyx, being very adherent along these ventral and dorsal midlines.

This fascia, including the corresponding area of the abdominal wall, is now for

convenience subdivided into two districts by a line drawn upward from the an-

terior superior iliac spine to the costal arch (about the ninth cartilage). Behind

this line is the dorso-lateral, and in front of it the ventral district. This line also

indicates fairly accurately where the muscle part of the external oblique ends

and becomes the broad flat tendon of the same, spoken of in most text books

as the aponeurosis, which term is certainly misleading and is invariably mis-

taken by students for fascia. (See also lat. dorsi.)

The term aponeurosis has two definitions, viz: (1) a thicken

of the ordinary deep fascia, and (2) a broad thin expanded

cle. The latter certainly applies to the broad ventral muscles

wall.

The Ventral District

Before proceeding with the fascia, that part of the tendo

oblique which occupies this district will be considered.

This tendon starts from behind at the line already indicated.

follows the edge of the costal cartilages to the ensiform car

edge the tendon lies on the thorax.

The anterior border extends downward from the ensiform ca

eral to the top of the symphysis pubis, then downward and

eral to the margin of the symphysis (extreme inner area of t

to the subpubic (arcuate) ligament. This entire border closel

the same border of the tendon of the opposite side. Along thphysis these decussations, together with the narrow part of

diately lateral to them, are almost inseparably united by the

downward extensions of the conjoined tendons, pyramidalis

rectus abdominalis tendons, which in their turn by close app

inner edges cover the anterior pubic ligament. Between the

and the top of the symphysis these decussations form a ra

linea alba, which is also contributed to by fibers from the ten

nal oblique and transversus abdominalis.

The lower border would run as follows, assuming for the pre

tence of the subcutaneous inguinal ring (superficial abdomin

the ant. sup. iliac spine to the pubic tubercle (or spine) this

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ament [Pouparts]; (2) medially along the pubic crest nearly to the top of the

symphysis across which the decussation occurs; (3) downward and backward

on the body of the pubis to the subpubic ligament just lateral to the midline. This

portion of the lower border, which really looks laterally, is in close contact with

the line of attachment to the body of the pubis of the gracilis and adductor

longus muscles. Thus between this line and the midline (symphysis) is a nar-

row ribbon-like strip of the tendon itself.

The inguinal ligament is a free edge. Although planes of fascia are closely at-tached to it above, below, in front and behind, it itself is not continuous with any

of these planes, as is intimated in some textbooks. Approximately the outer

two thirds is flattened and curved backward. The inner third is rounded.

The lacunar ligament (Gimbernats) is a thin expansion from, and a part of, the

inguinal ligament. It is triangular with the apex at the pubic tubercle. Of the

three borders, two are attached and one is free. The attached borders are,

each one, a little less than an inch long. The upper blends with the inguinal lig-

ament; the lower is attached to about the medial half of the pectineal line, the

inward prolongation of the iliopectineal line, (linea terminalis, linea arcuata).

The free border is curved, concavity directed laterally, and is the inner margin

of the femoral ring.

The subcutaneous inguinal ring is an opening or hiatus in the tendon of the

external oblique, which has just been described as if this opening did not exist.

We can now make this opening by cutting away and removing a triangular

strip of this tendon. The base of the ring is the lateral three-fourths or so of the

pubic crest (the size of the ring varies in different individuals). The inner or

upper edge begins along the medial fourth or so of the pubic crest and at the

top of the symphysis whence it runs upward and outward to the apex. Here it

joins the outer or lower edge which passe s, in its turn, downward an d forward

to the pubic tubercle. In fact this lower edge is the medial part of the inguinal

ligament. These edges are known as the pillars or crura of the ring, the inner

being somewhat the longer of the two. The distance from the apex to middle

of the base averages a little less than an inch.

Intercolumnar or intercrural fibers are to be considered as pa

of the main tendon. They must not be confounded with the in

tercrural fascia (q.v.).

The triangular or reflected inguinal ligament (of Colles) is a

fibers seemingly prolonged from the extreme lower part of th

tendon (i.e., just above the symphysis) of the opposite sidea short distance along the pectineal line close to the deep (

of the lacunar ligament, or it may fuse with it. In my expe

demonstrable and then only in a very muscular subject. It li

to the spermatic cord and superficial to the conjoined tend

subjects it seems to form a sort of floor of the ring and thus to

to the pubic crest.

Fascia of the Ventral District

The superficial layer of this fascia is fairly easily subdivided

which the superficial is commonly known as Campers fasci

Scarpas fascia. Traced downward along and over the inCampers fascia becomes the superficial layer of the super

thigh, while Scarpas fascia becomes the deep layer of the

be called the cribriform fascia, named from that part of it whi

fills in the fossa ovalis (saphenous opening.)

Traced downward under the skin of the scrotum and und

penis, Campers and Scarpas fascia fuse into one layer ble

considerable amount of smooth muscle. This fused fascia

dartos of scrotum and penis. The dartos is thin and delicate

ing, Campers fascia has lost practically all of its fat. It is we

in tracing this fascia and dartos that it must be done, not on

also upward almost to where it started from. In other words

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bag inside a skin bag which, like the latter, completely surrounds the testicle

and cord, so that Scarpas fascia is behind the spermatic cord as well as in

front of it. Similarly on the penis there is a fascial tube inside a skin tube (see

also scrotum, spermatic cord, perineum and penis).

As Scarpas fascia passes downward over the inguinal ligament it is closely ad-

herent to the corresponding underlying portion of the deep fascia (see below).

The deep layer of fascia of the ventral district is practically ignored in the textbooks as a distinct plane of tissue, whereas its direct extension on the thorax,

in the neck and on the extremities is carefully described. Its extension in the

perineum is also ignored.

This layer is distinct from the extremely delicate sheath proper (epimysium) of

the external oblique muscle. This distinction can be quite readily demonstrated

over the muscle part of the muscle. Over the tendon great care in the dissec-

tion is required.

Traced downward, this deep fascia (fascia innominata because hitherto un-

named), together with the overlying Scarpas fascia, is strongly adherent along

the whole length of the inguinal ligament, and is then continuous with or be-comes the fascia lata (deep fascia) of the thigh (Fig. 1). However, after pass-

ing over, or leaving, the extreme medial end of the inguinal ligament, i.e., the

lower or lateral pillar of the ring, the fascia passes obliquely backward, cover-

ing the under surface of the lacunar ligament, and then downward over the

pectineus muscle (pubic or pectineal portion of the fascia lata).

Along the boundaries of the subcutaneous inguinal ring (q.v.) this fascia is at-

tached, and is then prolonged as a tubular investment over, i.e., superficial to,

three other tubular investments of the vas deferens (ductus efferens), to be

discussed later.

This tubular prolongation lies deep to (within) the dartos and is known vari-

ously as the external spermatic fascia, the intercolumnar fa

crural fascia. From the line of attachment of this tube to th

(pubic crest) of the ring, this same fascia is reflected downw

bic ligament, thus covering the narrow area of the extreme low

don of the external oblique muscle (q.v.). The attachment to

fairly close while there is no attachment, along this line, of Sc

ilar to that already mentioned along the inguinal ligament.

This downward reflection of the external spermatic fascia is cthe midline with the corresponding reflection of the fascia of

Traced laterally, on each side, this lamina of fascia becomes

does so after passing over and being adherent to the ridges w

of attachment to the bodies of the pubic bones of the adducto

cilis muscles. Furthermore Scarpas fascia along these ridges

deep fascia.

Below, on reaching the subpubic ligament, this fascia unde

bular prolongation over and around the penis (q.v.) and the

ferior perineal fascia (see perineum).

The Dorso-lateral District

The anterior boundary is the posterior boundary of the vent

described. The other boundaries are: above, a line running

about the ninth to the twelfth costal cartilage and then alon

the spinous process of the twelfth thoracic vertebra; behin

over the spinous processes of all the vertebrae from the twe

end of the sacrum and tip of the coccyx; below, a line which

and indicates not only an inferior, but also a lateral, bounda

the anterior superior iliac spine. It then follows the outer lipilium and the attachments of the gluteus maximus to the sa

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The superficial muscles of this district comprise portions of the external oblique,

lat. dorsi and a small extent of the int. obl., viz., the floor of Petits triangle. This

portion of the ext. obl. is muscle, but also comprises most of its posterior ten-

don. The attachments of this portion of the tendon, behind and below, are prac-

tically the same as the corresponding boundaries just described of the

dorsolateral district. This tendon covers the sacrospinalis muscle and then is

closely adherent along a very narrow vertical line to the posterior tendon of the

transversus abd. muscle, the larger part of which arises from the tips of the

transverse processes of the lumbar vertebrae. This posterior tendon of the lat.dorsi is called in all the textbooks by one or other of the following names: lum-

bosacral aponeurosis, posterior layer of the lumbar fascia, posterior layer of the

lumbodorsal fascia.

The real fascia of this district has already been mentioned and will be referred

to again. Of the names just mentioned, the one most commonly used is pos-

terior layer of the lumbodorsal fascia. The lumbodorsal fascia is described as

having three layers: (1) the posterior is the posterior tendon of the lat. dorsi al-

ready described; (2) the middle layer is the posterior tendon of the trans. abd.

muscle (see above) of which the anterior tendon forms part of the sheath of the

rectus abd.

Out to the line of adhesion between them, already mentioned, these posterior

tendons enclose the sacrospinalis muscle. Slightly lateral to this line of adhe-

sion, numerous muscular fibers of the int. obl. muscle are attached to or take

origin from the tendon of the trans. abd.

(3) The anterior layer of the lumbodorsal fascia is simply that portion of the

transversalis fascia (intra-abdominal fascia, q.v.) which covers the ventral sur-

face of the quadratus lumb. muscle, of which the dorsal surface is in contact

with the tendon of the trans. abd. muscle, just described (Fig. 2). It would thus

seem that there is no such anatomical entity or unit as the lumbodorsal fascia.

Hence the abolition of this term and its synonyms together with its layers would

be advisable.

The extra-abdominal fascia which occupies this dorso lat

properly be called the lumbodorsal fascia. There is a deep

layer, the latter corresponding to, and continuous with, Camp

fascia of the ventral district. Superiorly this fascia is conti

sponding layers of back and thorax while inferiorly it passes i

the fascia of the lower extremity and, from the coccyx, with th

ineum (q.v.).

Along the irregular line of the inferior bounda ry, we have intthe deep fascia and of Scarpas fascia. After crossing this l

cia becomes the fascia lata (gluteal portion) of the thigh, wh

becomes the same layer as the cribriform fascia anteriorly

tioned.

There are certain deep lying strata or laminae of the deep l

abdominal fascia which require brief mention. They are limite

are derivatives of the main lamina of deep fascia being exa

when the main lamina meets free edges of muscles, or other

Examples of such edges are those of ext. obl. and lat. dors

abd. and pectoral muscles on the thorax; trap., sterno-mahyoid muscles in the neck, including pharynx, oesophagus

thyroid etc. These strata of thorax and neck link up with the

upper extremity at the apex of the axilla and superior apertu

The vertebral aponeurosis may be mentioned. It is fascia,

lying strata just mentioned, and covers the entire sacrospin

deep to the tendons of the lat. dorsi and trapezius muscles a

serratus posterior muscles, many of the fibers of which take

The Intra-abdominal Fascia

As already stated, under systemic fasciae, there are two la

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toneal (or subserous) areolar tissue or superficial intra-abdominal fasciae, and

the deep intra-abdominal fascia commonly called the transversalis fascia.

Inasmuch as the pelvis or pelvic cavity is regarded as part of the abdomen or

abdominal cavity, the intra-abdominal fascia (both layers) must be and is con-

tinued into the pelvis. Here both layers constitute the pelvic fascia, i.e., the su-

perficial pelvic fascia and the deep pelvic fascia, the former of which, of course,

lies immediately under, or next to, the pelvic peritoneum.

With this distinction between the abdomen and pelvis, we may consider thetransversalis fascia as that part of the deep intra-abdominal fascia which lies

above the brim of the pelvis, (linea arcuata, linea terminalis, and ileopectineal

line). This line crosses the sacrum at a level just below the promontory.

The Transversalis Fascia

This lines the abdominal cavity. It is really a sort of bag, with its outside surface

in contact with the abdominal wall and its inside surface in contact with the

parietal portion of the subperitoneal areolar tissue. The transversalis fascia

covers the muscles and invests the nerves, the aorta, post cava and lumbar

vessels, thus splitting as previously described. It is fairly closely adherent along

the pelvic brim except the sacral portion of the brim, an example of adhesionto edges already referred to.

It has certain prolongations, one of which is a regular tubular examination, be-

ginning at the upper end of the inguinal canal (see below) and continuing down

through the canal and superficial ring, covering the ductus efferens and the

testicle. This evagination is called the infundibuliform fascia or the internal sper-

matic fascia (see Cord and Testicle). In the canal this tubular evagination lies

against (in front of) the main lamina of transversalis fascia from which it is de-

rived.

The upper end of the inguinal canal is halfway between the pubic tubercle and

anterior superior iliac spine. Between these points the floor of the canal is

formed by the adhesion to the inguinal ligament of the mai

versalis fascia just referred to. This adhesion continues up

Then the transversalis fascia curves backward and upwar

iopsoas muscle, etc.

The entire line of this adhesion, however, is continuous with

neath (deep to) the inguinal ligament; while above (superficia

the fascia lata is continuous with the fascia innominata (see

example, tracing it upward, of one layer of fascia splitting intoa sharp edge (inguinal ligament, Fig. 1).

The sheath of the femoral vessels is another downward p

other prolongations pass upward. Each may be considered a

ting and investing. There are two groups, (1) passing throug

behind, the diaphragm.

Group 1. These layers pass through the openings in the d

aorta (which strictly speaking passes behind the diaphragm)

azygos veins, splanchnic nerves and sympathetic cord. In

link up with the endothoracic fascia (Fig. 3). There is no up

for the inf. vena cava. As this vessel passes through its opeof the diaphragm, the fascia spreads out under the diaphra

the main layer. Furthermore, this fascia as a gross structure

the vena cava where this vessel is in contact with the liver.

Group 2. Prolongations passing behind the diaphragm. B

these specifically, we will trace the fascia laterally, i.e., aroun

abdominal wall, the level being anywhere between the las

crest, beginning at the ventral midline, where it is continuou

the fascia of the opposite side. The transversalis fascia now

surface of the trans. abd. muscle, first its anterior tendon, t

part and then the posterior tendon as far as the outer edge

muscle. It now covers the anterior surface of the quad. lumb

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substantial and is the anterior layer of the lumbodorsal fascia of the textbooks),

the psoas (magnus and parvus) and then invests the aorta, vena cava and

sympathetic nerve trunks (Fig. 2). As it lies over the quad. lumb. and psoas, it

also covers and invests the twelfth thoracic nerve (ant. ramus) and the de-

scending branches of the lumbar plexus. This portion, furthermore, passes be-

hind the kidneys, adrenals, oesophagus, pancreas and duodenum. At the

anterior edge of the quad lumb. it sends off a very delicate lamina which goes

behind the muscle, i.e., between it and the posterior tendon of the trans. abd.

Before tracing upward those portions of the transversalis fascia which cover the

psoas and quad lumb. muscles, the following will be in order. Each crus of the

diaphragm has a narrow median border of tendon which unites with the one of

the opposite side across (ventral to) the aorta forming the middle arcuate lig-

ament from which some of the muscular fibers of the diaphragm arise. From

this tendinous edge of each crus, at about the level of the disc between the first

and second lumbar vertebrae, is prolonged laterally another narrow tendinous

edge which curves across the psoas (the latter going up behind it), to be at-

tached close to the tip of the transverse process of the first lumbar vertebrae.

This is the medal lumbocostal arch, from which also muscular fibers of the di-

aphragm arise.

Another similar tendinou s edge arises from where the first one ends and

crosses the quad. lumb. to be attached to the twelfth rib just beyond the line

of attachment to this rib of the quad. lumb. This is the lateral lumbocostal arch

and it also gives origin to muscular fibers of the diaphragm. These lumbocostal

arches are also called medial and lateral arcuate ligaments. Counting with

them the middle one, the five make a continuous edge to the diaphragm like

the selvage of a piece of cloth.

Tracing the transversalis fascia upward: this narrow tendinous edge is held

closely to the quad. lumb. psoas and aorta by the transversalis fascia which not

only becomes more substantial along this edge, but splits into two layers, one

becoming the layer on the under surface of the diaphragm and the other, Group

(2) of upward prolongations, passing up behind it to blend o

uous with the endothoracic fascia (Fig. 3). Occasionally a f

of the psoas arise from the inner end of the medial lumboco

The transversalis fascia is extremely delicate in three districts

surface of the tendon of the diaphragm, and behind the anter

trans. abd. muscle where the latter passes, together with th

of the tendon of the int. obl., behind the rectus abd., i.e., a

semicircular line (fold of Douglas). Below this, now directly irectus, it resumes its normal consistency. In these districts it

often impossible to separate it (without tearing) from the sub

tissue lying between it and the peritoneum. The iliac fascia

necessary name for that portion of the transversalis fascia w

iacus muscle (fig. 1).

The Superficial Intra-abdominal Fascia

Synonyms: Tela subserosa, subperitoneal (or subserous) are

the pelvic brim it is (or becomes) the superficial pelvic fasc

running through this superficial subserous fascia are all arter

cept the aorta, inferior vena cava and lumbar vessels), the vlymphatics and nodes, and sympathetic nerve fibers to visc

This fascia, as before stated, contains the fat. In very thin s

delicate sheet of areolar tissue connecting and supporting

etc. This fascia also sends direct prolongations to those vi

mesenteries. In each case these prolongations run betwee

corresponding mesentery, and carry the blood-vascular, lym

supply. On actually reaching the viscus toward which it run

tion ceases as fascia (a gross structure) and blends with th

of the organ, i.e., the fibro-elastic stroma of the tunica seros

the intestines, or with the capsule of the liver. These are in

cera. The mesenteries of course include the omenta and i

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seemingly mere masses of fat covered on both sides by a glistening surface,

the peritoneum.

In the case of the extraperitoneal viscera (also known as sub or retroperi-

toneal), a delicate layer of fascia is found on stripping off the peritoneum. This

covers the organ (front and back), e.g., the duodenum, except the proximal

portion which is always intraperitoneal, as is also the terminal portion when

there is a retroduodenal fossa; and the pancreas.

As regards the kidneys, the above arrangement is very marked . Thus, the su-

perficial intra-abdominal fascia, a little below the lower pole of the kidney, splits

into two layers which pass upward one in front of the other behind the organ,

including the adrenal. These layers unite above and along the margins of the

kidney. From the union along the medial border, especially at the hilum,

processes are sent outward into the sinus and inward toward the aorta and

vena cava, thus investing the renal and adrenal vessels, nerves etc. At their ori-

gins from aorta and cava these vascular branches necessarily pierce this fas-

cia in order to become invested by it.

We thus have a sort of pocket in which the kidney and adrenal are lodged. The

above holds good for very thin subjects. In most subjects, however, especiallyin fat ones, there are found special deposits or pads of fat located as follows:

(1) Between the two layers, often extending up onto the kidney; (2) in front of

the anterior layer, i.e., between this and the peritoneum; (3) behind the poste-

rior layer, i.e., between it and the transversalis fascia.

This entire arrangement is called the perirenal fascia or the fatty capsule of

the kidney, not to be confounded with the true capsule of the kidney, which is

part of the kidney structure proper.

Along the inguinal can al there is a tubular e vagination of this superficial intra-

abdominal fascia, precisely like that of the deep fascia (see above). It is very

thin and lies close to the vas (round ligament in the female), and testicle, the

tunica vaginals of the latter being immediately deep to it. It

lar supply of the testicle, vas and cremaster. It may be called

matic fascia or the vascular layer of the cord (q.v.). I

superabundance of fat, which in some cases is so marke

what is called lipoma of the cord (see also labium majus).

The Pelvic Fascia

This fascia is that portion of the intra-abdominal fascia whbrim of the pelvis, and similarly has two divisions: superficial

deep pelvic fascia.

The Deep Pelvic Fascia

This is the continuation into the pelvis of the transversalis fa

In considering the deep pelvic fascia it will be necessary to

reference to the perineum and perineal fascia, owing to the

between the two fasciae. The brim of the pelvis is also calle

The Pelvic Outlet. Its boundaries, outlining a rhomboid, are: apoint of the subpubic (arcuate) ligament; from here, outwa

the rami of pubis and ischium to the ischial tuberosities; the

ous ligaments to the side of sacrum and first two pieces of t

of the latter being the midpoint posteriorly. The pelvic outle

same area as the perineum, using this term in its broad

below). A transverse line between the anterior ends (tips) of th

ties, and passing in front of the anus, gives us two triangles

angle is known as the urogenital triangle and the posterior

triangle. The anterior triangle in the fresh state is also called

gle, the urethral perineum or simply the perineum (in its n

see above). Hereafter the word perineum will always be us

meaning. In the female, however, perineum is applied also t

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between the front of the anus and the back of the vagina (rarely so in the male).

This surface is really the base of the perineal body (see perineum).

The posterior of these two triangles is also called the anal perineum. A better

name is the ischiorectal triangle because (in the fresh state) it contains on each

side the ischiorectal fossa between which is the lower part of the rectum (anal

canal) and the anus. Hence the pelvic outlet comprises the urogenital triangle,

(or perineum) and the ischiorectal triangle. (Many textbooks use the Greek

word trigone or trigonum instead of triangle).

The diaphragms of the pelvic outlet: (1) The urogenital diaphragm. This

stretches across between the lateral and anterior boundaries of the urogenital

triangle. It consists of a muscle sheet lying between two layers (upper and

lower) of fascia which together are known as the triangular ligament of the per-

ineum (q.v.). Posteriorly these two layers unite. This diaphragm lies between

two other musculofascial strata (see levator ani and perineum), all three of

which really constitute the diaphragm.

(2)The pelvic diaphragm. This consists of the levator ani and coccygeus mus-

cles together with the fascia covering them above and below, that above being

the deep pelvic fascia (supra-anal fascia; or the superior layer of the pelvic di-aphragmatic fascia); and that below, the infra-anal fascia (see below).

To resume: the deep pelvic fascia will be traced at different levels and in dif-

ferent directions, beginning at the pelvic diaphragm.

The muscles of the pelvic diaphragm: The coccygeus. This extends from the

ischial spine to the sides of the lower part of the sacrum and upper part of the

coccyx, including the lower margin and inner third of the sacrotuberous liga-

ment to which it is attached. Thus the deep pelvic fascia covers this district

evenly from one ischial spine to the other, overlying the two coccygeus mus-

cles, the intervening bones and nerves, and passing behind the rectum. It is the

posterior portion of what is called the superior layer of the pelvic diaphragmatic

fascia (see above and below).

The levator ani. It is unnecessary to describe its various su

muscle is a curved (convexity outward and downward) she

ing outward, upward and forward from a common origin b

This common origin is: (1) the sides of the lower part of the

and (2) the ano-coccygeal raphe (ligament) which runs betw

coccyx and the back of the anus.

From this origin: (1) The posterior fibers run outward to the is

to and parallel with the lower border of the coccygeus, receiv

surface a prolongation of the deep pelvic fascia covering

known as the supra-anal fascia (see above and below). (2

medial) fibers including those from the tip of the coccyx are th

forward, something like an old fashioned hammock, to the b

the pubis to a point halfway between its upper and lower bor

between the symphysis and median border of the obtura

brevity this point will hereafter be called the pubic point. (3)

fibers, or ilio-coccygeus muscle, spray outward, upward an

and end, if all fascia is removed, in a free edge, slightly curv

ward, which extends from just lateral to the pubic point to th

The free edges or borders of the lev. ani muscle: We have a

viz. (1) parallel to the coccygeus and (2) the one just men

third free edge. Considering again the anterior or medial fibe

coccyx and anococcygeal raphe lying, along this line, above

iococcygeus, to the pubic point. These fibers are called the

muscle. On leaving the anterior end of the anococcygeal r

coccygeus muscle, encircles half of the lower part of the re

just lateral to the ext. sphincter ani, and then , after a mutual e

fibers in front of the anal canal, proceeds, independently o

pubic point, now uncovered below by the iliococcygeus. Thus

a free medial edge with an appreciable interval between t

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talis). By removing the anal canal and sphincter ani, this interval would be ex-

tended back to the anterior end of the anococcygeal raphe.

We will now consider that part of the deep pelvic fascia which lies below the

upper edges and on the upper surfaces of the lev. ani muscles. It is part of the

superior layer of the pelvic diaphragmatic fascia; or preferably known as the

supra-anal fascia already mentioned (see post, fibers of lev. ani).

This supra-anal fascia continued from behind, forward from the coccygei mus-cles (see above), covers the entire inner (upper) surface of both lev. ani mus-

cles. Traced from side to side beginning at the upper free edge (see above), it

sweeps across the raphe behind the anal canal, blends with the anal canal,

and in front of this passes from the upper surface and edge of one pubococ-

cygeus muscle to that of the other, thus filling in the hiatus genitalis (see

above). Since in part of this interval is the lower portion of the back of the sym-

physis and a narrow area of bone on each side, this same fascia traced forward

and upward would cover this bone interval and at its upper margin become the

transversalis fascia. In thus covering this bone interval, it is well to state now

that this fascia really has between itself and the bone interval the upward pro-

longation of the upper (deep) layer of the triangular ligament of the perineum.

This layer joins with the supra-anal fascia to form the transversalis fascia justbelow the upper margin of this bone interval (Fig. 4).

Hence most of the under surfaces of the pubococcygeus muscles, together

with the fascia (just referred to) between their edges lies immediately over and

on the upper surface of the deep layer of the triangular ligament of the per-

ineum. Thus this musculofascial plane forms a superstratum of the uro-geni-

tal diaphragm (q.v.). Thus this pubococcygeal portion of the levator ani lies

between the supra-anal fascia above and the superior (deep) layer of the tri-

angular ligament of the perineum below (Fig. 5).

This inter-pubococcygeal interval, bridged over by supra-anal fascia, has just

been described as if no organs (except the anal canal) existed in this interval.

As a matter of fact certain organs or rathe r parts of them ar

Thus in the male: The prostate gland (lower surface) lies in

the supra-anal fascia invests the gland, i.e., splits and surrou

capsule, which is to be distinguished from its sheath which

perficial pelvic fascia (q.v.). Inasmuch as the capsule canno

from the gland without causing the gland substances to sp

better from a gross point of view to say that the supra-anal

the capsule.

Considering the above arrangement more in detail and as

sence of the superficial pelvic fascia:

The prostate has five surfaces: two lateral, one superior, on

posterior, and an apex directed upward and forward owing

(upward) of the superior (vesical) surface on which is the bl

rior (rectal) surface is convex up and down and slightly con

side. The lateral surfaces are convex from before backward

upward. The inferior surface is also convex (downward) from

All s urfaces except the rectal converge to and from the ape

projection looking toward and fairly close to the lower part and which is free.

The inferior surface may be divided by the junction of the uret

branous urethra (between the two layers of the triangular liga

surface (free) and a perineal surface, of which the former is

apex. Similarly the concave vesical surface is prolonged on

there is a slight interval between the apex and the bladde

faces of course begin at the tip of the apex.

The perineal surface: This occupies, from side to side, per

than the middle third of the triangular ligament. Posteriorly thi

extend quite to the free edge of the triangular ligament, but

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blend imperceptibly with the rectal surface. There is thus an interval or cleft

between the gland and the triangular ligament. The supra-anal fascia running

forward from the anal canal runs over the triangular ligament (more or less ad-

herent to it) into this cleft and then backward and upward on the gland as part

of its capsule. Along the lateral margins of the perineal surface the supra-anal

fascia is similarly attached, i.e., blends with, or becomes continuous with, that

part of the capsule which is reflected up over the lateral surfaces (Fig. 5).

The perineal surface itself is covered by a fusion of supra-anal fascia with theupper layer of the triangular ligament, which combination of course fuses with,

as it surrounds, the urethra; while anterior to the urethra the apex is entirely

surrounded by capsule.

The capsule on the rounded under surface of the apex, followed backward to

the urethra, makes an angle with and is continuous with the forward and up-

ward continuation of the supra-anal fascia (already described) to the back of

the symphysis and to the two pubic points. This particular area of the supra-

anal fascia is often specially thickened and forms what is called the pubopro-

static ligament. Sometimes this thickening is confined to three strands, a

middle (from the symphysis), and two lateral (one from each pubic point) pub-

oprostatic ligaments. Each of the two latter is a prolongation of the white line(see below).

The vesical surface of the prostate is very closely united to the bladder by a fu-

sion of the capsule with a thin but condensed layer of superficial pelvic fascia

(q.v.).

In the female: The vagina and urethra are situated in this interval or more ac-

curately the extreme lower ends of the pelvic portions of these structures. (It

should be recalled that both vagina and female urethra have three divisions,

pelvic, membranous and vestibular: The first extending to the triangular liga-

ment; the second lying between the layers of the triangular ligament; and the

third situated in the vestibule of the vulva).

As they lie in this pubococcygeal interval, the supra-anal f

them, i.e., with their extreme lower ends.

From the closely approximated inner margins of the pubo-co

lar fibers, difficult to dissect grossly, run to and blend with

structures, and these have received special names: to the an

pubo-rectalis, rectococcygeus; to the vagina, pubo-vagina

founded with the deep or urogenital sphincter); the pubo-u

urethrae (in both sexes); and the levator prostatae (prostate

The pubo-urethral ligaments are slight thickenings of the

which are attached to the lower end of the (female) pelvic u

respond to the pubo-prostatic ligaments in the male.

Returning to the upper free edge of the lev. ani already men

runs, usually as a gentle curve, concavity upward, between

and pubic point. It lies against the inner surface of the obt.

two thirds or less of this surface being above this edge. From

inward this edge is in line with the upper margin of the cocc

Now it is along this line, i.e., the upper edges of the coccythat the deep pelvic fascia splits when traced downward fro

Considering first the free edge of the levator ani: This is held q

the obturator internus by the split just referred to. This split o

ina covering the inner surface of the obt. int. is in three laye

layers, two invest the lev. ani; i.e., one lies on each surface

the third covers the lower third of the obt. int. Between the l

ally, and that covering the outer (under) surface of the lev.

space, the ischiorectal fossa. The curved line along which t

thickened and shows as a distinct white line also called the w

tendineus of the lev. ani (Fig. 6).

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Exactly the same thing occurs along the upper margin of the coccygeus except

(1) for the absence of a white line, and (2) that the original lamina covers the

pyriformis muscle, i.e., traced downward from its upper border.

Thus the upper surfaces of coccygeus and lev. ani are covered by the same

layer of fascia, a fact already spoken of, and the same is true for their lower sur-

faces; while, considering the coccygeus alone, the third layer is simply the ex-

treme back part of the layer already mentioned as covering the obt. int. muscle,

i.e., where that muscle narrows to its tendon just at its emergence through thelesser ischiatic foramen. Nomenclature: Before further tracing the deep pelvic

fascia, a few names may be considered. (The reader may be reminded that so

far the superficial pelvic fascia has not been described beyond a few casual ref-

erences; to which fascia many names are also attached.)

From the pelvic brim to the white line is called by some the obturator fascia.

This continues down (under the same name) over the lower third of the mus-

cle. In this case the obturator fascia, at the white line would send off the two

layers, investing the levator ani (supra- and infra-anal fasciae).

These two investing layers (upper and lower) are called, by some, respectively

the superior layer of the pelvic diaphragmatic fascia and the inferior layer of thepelvic diaphragmatic fascia. These names, however accurate, are cumber-

some. Furthermore, it is not made clear by the users of these names that the

respective fasciae also cover the coccygeus in an exactly similar manner. For

clearness, therefore, we have already designated the upper one of the two lay-

ers as the supra-anal fascia, and shall call the lower, the infra-anal fascia. This

latter has, for years in the so-called old nomenclature, been called the anal

fascia. These names indicate antero-inferiorly the general trend of these fas-

ciae. The supra-anal fascia is called by some authorities the parietal layer of

the pelvic fascia.

To sum up, using the author's nomenclature: Traced from the pelvic brim to

the upper borders of the coccygeus and lev. ani, the fascia is the deep pelvic

fascia, which along these borders splits into three layers: s

infra-anal fascia and obturator fascia (Fig. 6).

Before taking up these layers separately, attention should be

ineal ramus, i.e., the descending ramus of the pubis and th

chium. This shaft of bone has three borders: (1) superola

boundary of the obturator foramen; (2) inferolateral; (3) media

sharp, the third is rounded. For brevity the first and second m

spectively "lateral" and "inferior." Of these three borders thdial are of present interest.

The infra-anal and obturator fasciae. These have already

above downward. Between the upper portion of the former

fascia is a space, the ischiorectal fossa. Tracing these fasc

inward, they meet and unite along the upper border of the c

lower edge of the sacrospinous ligament, to which edge t

This attachment also holds the coccygeus onto and along th

angle of junction between these fasciae is the extreme poste

chiorectal fossa, but it is overhung by a small part of the lo

glut. max. which is covered in its turn by a fascial prolongat

junction. Thus a po cket of the fos sa is formed.

Tracing this upper portion of the infra-anal, and obturator,

perineum, they meet and unite along the whole length of the

the perineal ramus. This particular tracing is along a horiz

meeting and uniting, these layers split in two and continue rig

genital triangle forming, together with the constrictor urethra

them, the middle stratum of the urogenital diaphragm; while

themselves are known as the triangular ligament of the pe

(deep) layer of which may be regarded as the prolongatio

fascia from side to side; the lower layer is similarly a prolong

side of the obturator fascia. Posteriorly these layers unite a

transversely between the front ends of the ischial tuberositi

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together with the lower portion of the infra-anal fascia, will be further consid-

ered under perineum.

The supra-anal fascia has already been described, i.e., below the white line

and the upper edge of the coccygeus muscle.

From the pelvic brim down to the upper margin of lev. ani and coccygeus: The

deep pelvic fascia traced from above downward or from side to side covers

the upper part of the obt. int., the pyriformis, the sacral and pudendal plexuses

and the mid-region of the sacrum; and of course passes behind the rectum.

The pyriformis: The deep pelvic fascia really splits along the upper border: The

front layer has just been mentioned. The back layer, now extrapelvic, covers

the posterior surface of the muscle, links up with the front layer along its lower

border and becomes part of the deep fascia (fascia lata system) of the gluteal

region.

The obt. int. A similar splitting of the fascia occurs along that margin of the

muscle, above the ischial spine, which looks toward the sacrum. This margin

and a portion of the lateral surface of the muscle anterior to it are free so that

the secondary split or lamina goes around the margin and on to this surface

and fuses with the obturator membrane. The extreme lower part of this laminagoes out of the pelvis with (and investing) the muscle through the lesser sci-

atic notch and, becoming extrapelvic, covers the gemelli. A prolongation of the

original layer accompanies the obturator nerve and vessels through the obtu-

rator canal. Another prolongation roofs in Alcock's canal.

The Superficial Pelvic Fascia

This is the continuation of the superficial intra-abdominal fascia into the pelvis,

and similarly, is subperitoneal or sub-serous. Hence it may also be called the

subperitoneal or subserous pelvic fascia.

It is of fatty consistency speaking generally and from a gross point of view. In

lean subjects the fatty consistency is scarcely apparent a

comes more like areolar tissue. In certain regions (to be sp

thicker and more substantial than in others; while in other r

in the pelvis, especially in the female, this fascia contains

smooth muscle fibers, "loose fatty areolar tissue, and well d

cular and elastic bands." (Edward Martin, Berlin; quotation fro

nald M. Rawls, M.D., New York, N. Y., in New York State Jo

July 1, 1929).

As a matter of gross dissection, without regard to histologi

fascia is a sheet of tissue which tucks into and fills up all spa

(1) between the deep pelvic fascia and its prolongation (e.

fascia), on the one hand, and the peritoneum on the other

fascia just mentioned and the viscera; (3) between the vis

and (4) between the viscera and peritoneum.

This subserous pelvic fascia cannot be split definitely into lay

and Scarpa's fascia; but it has running through it, or situate

it, all the blood vessels, lymphatics and lymph nodes of the

filaments, both sympathetic and those from lower sacral nerv

ureter and the vas deferens (ductus efferens).

This fascia as a whole has received many names, among

lowing: tela or tunica adiposa of the pelvis; fascia endopelv

of the pelvic fascia; rectovesical fascia. It has even been de

diagrams in Cunningham's Dissector, as a direct offshoot

the deep pelvic (supra-anal) fascia. The term recto-vesica

this article with but a very restricted meaning (see below).

Posteriorly this fascia passes behind the rectum and acros

with the deep pelvic fascia intervening between it and the sa

retrorectal portion traced upward behind the rectum from th

third sacral vertebra, where the rectum begins, becomes the

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est part of the tissue between the layers of the mesosigmoideum (most infe-

rior segment of the pelvic mesocolon).

The first part of the rectum extends from the point above mentioned to the am-

pulla (second part). It is covered by peritoneum on its sides and in front. Hence,

it has on these areas, grossly, no subserous tissue or superficial pelvic fascia.

On the other hand the ampulla and the upper part of the anal canal (third divi-

sion of the rectum) are devoid of peritoneum and are completely invested by

and imbedded in the superficial pelvic fascia, which is now quite thick and fairly

dense.

From this perirectal (meaning around ampulla and upper part of anal canal) re-

gion this fascia is continued as a thick soft lamina around and between all the

pelvic viscera forward to the back and top of the symphysis pubis. Laterally,

below and in front, it lies closely applied to the supra-anal (deep pelvic) fascia.

This mass of fascia thus briefly outlined may be considered as the lower stra-

tum of the superficial pelvic fascia. Its upper surface in all directions is curved,

concavity upward, and is covered by peritoneum. From the lateral margin of

this lower stratum, the fascia is continued upward on each side as a thin lam-

ina to the brim of the pelvis, becoming there the superficial (subserous) intra-

abdominal fascia. These laminae are covered medially by peritoneum, andmay be called the upper strata of the superficial pelvic fascia.

These laminae are continued around laterally and posteriorly behind the first

part of the rectum, where they blend to form the retrorectal tissue already re-

ferred to. Each lamina is pierced by the obturator vessels at the beginning of

the obturator canal.

Description, more in detail: Male. A fairly thick mass of this fascia occupies the

space bounded as follows: behind by the rectum, i.e., the ampulla and begin-

ning of the anal canal; and in front by the base (fundus) of the bladder, the am-

pullae of the vasa deferentia, the seminal vesicles and the posterior (rectal)

surface of the prostate. This particular sheet of fascia is the recto-vesical fas-

cia. From side to side: it is wide above, corresponding to the

der and rectal ampulla, but narrow below, corresponding to

contracted rectal ampulla which here joins the anal canal. O

proximity of the rectum to the prostate, the intervening p

tovesical fascia (rectoprostatic fascia) is thin but quite subs

so than the supra-anal fascia underlying it. This fascia, as it

rior (rectal) surface of the prostate, is really in close contac

of the prostate (see above); but its separation from the cap

is easily demonstrable. This is also true of its lateral exten

sides and apex of the prostate. This closely-enveloping pros

rectovesical fascia is the sheath of the prostate, in contradis

sule. This sheath is traceable on the inferior surface of the g

very thin and blends near or at the urethra with the capsule (

anal fascia (below).

Around the apex of the gland, this sheath is merely part of

ovesical fascia (see below). On the upper or vesical surfac

sheath is thin but dense, and blends with the capsule. This

not only is the upper part of the prostatic sheath, but also is

sion of the lateral true ligaments of the bladder (see below)

To return to what has been called the rectoprostatic fascia: T

ina or segment of the rectovesical fascia has been called the

rosis of Denonvillier, also Tyrrell's fascia. It has been describe

an "ill-defined fibromuscular layer" extending from (i.e., co

upper layer of the triangular ligament of the perineum. Its up

fined. This idea is not at all in accord with the present desc

diagram of Denonvillier's fascia in an article in Surgery, Gy

stetrics, February, 1927. The author of the article is Miley B

San Francisco. I do not agree with the anatomy of this diag

doubt that the sheath of the prostate does limit backward

urine, as described in the article, provided the rupture of th

junction of its prostatic and membrano us portions. Anothe

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nonvillier's fascia, which seems to me to be totally wrong, appears on page

461 of Gray's Anatomy (Da Costa and Spitzka) 1908.

To return to the rectovesical fascia: as stated, it lies between the rectal am-

pulla and the base of the bladder. Above, it is curved, concavity upward, and

this concavity is covered by a layer of peritoneum, the rectovesical lamina. On

each side of this concavity the fascia is raised into a curved ridge which passes

backward and blends, or becomes continuous with, the perirectal and retrorec-

tal fascia already mentioned. These curved ridges of rectovesical fascia are the

so-called posterior true ligaments of the bladder. Each is covered by a fold

(plica) of peritoneum continued upward from the rectovesical lamina, just men-

tioned. Each plica of course has a free edge of which the lateral leaflet is con-

tinued downward and backward covering the pararectal portion of the

rectovesical fascia and thus forming the pararectal fossa. Both plicae are called

the folds of Douglas, or the rectovesical folds or the posterior false ligaments

of the bladder. These plicae are connected on and across the bladder by a fold

(usually demonstrable) of peritoneum which runs across the base line of the tri-

angular area known as the base or fundus of the bladder. Between the layers

of peritoneum which make the lateral ends of this fold, runs medially the lower

end of the vas just before it bends downward (now extraperitoneal) on the sur-

face of the bladder (see above).

This fold is often considered as one structure with the plicae, viz: the geni-

tosacral fold (homologue of the broad ligament in the female). The space

bounded by the rectovesical lamina and the rectovesical folds is the rec-

tovesical pouch, fossa, or excavation.

The rectovesical and pararectal fascia is continued forward right around the

sides of the bladder into and filling up the space of Retzius between the back

of the symphysis and the pubic (non-peritoneal) surface of the bladder. This is

a thick layer of considerable density and usually contains fat. Its attachment to

the bladder is close and it is then reflected as a thin layer over the bladder and

is now covered by the peritoneum lying on the abdominal surface of the organ.

From its attachment to the bladder laterally it reaches to, an

supra-anal fascia, possessing an appreciable curved (from s

surface (concavity upward) which, when covered by perito

the paravesical fossa. Its attachment to the supra-anal fas

parallel with and about one-half inch or less below the white

This rather substantial layer of fascia on each side is the so

ligament of the bladder; while the layer of peritoneum over

the paravesical fossa, is the so-called lateral false ligament o

tension of the bladder increases the depth of the fossa.

The upper line of attachment of this fascia to the supra-an

ferred to, is considered by some to form another white line or

fascia. I could never satisfactorily, if at all, demonstrate this

it must not be confused with the true white line of the supra

The pubovesical ligaments are parts of the lateral true vesica

demonstrable there are three of these special fascial thicken

and two lateral. They all run to the bladder above the apex o

lateral from the pubic points (see above) and the median fro

symphysis.

Female. This fascia has the same general disposition as tha

portant modifications are due to the presence of the uterus, t

vagina; and to the absence of the prostate.

What corresponds to the rectoprostatic and rectovesical fas

now the rectovaginal fascia, but a much more substantial la

tions. It contains much smooth muscle tissue. This lamina ab

the rectovaginal fold or layer of peritoneum forming the bo

vaginal pouch (pouch of Douglas), resembling the rectove

male. Posteriorly this fascia extends around and behind the

close contact with the deep pelvic fascia covering the levat

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pyriformis and sacrum.

This backward extension to rectum, etc. just mentioned has a free upper edge

on each side. These edges and the fascia of which they are the edges contain

much smooth muscle tissue (uterorectal muscle); while the strand to and

across the sacrum is the uterosacral ligament. The edges themselves are cov-

ered by peritoneum continued upward from the rectovaginal fold. Thus are

formed the uterorectal folds or plicae. Each plica at first is single but about

halfway back to the rectum it very frequently splits into two folds, one going to

the rectum and the other to the sacrum. This means of course a similar split-

ting of the underlying fascia (uterorectal muscle and uterosacral ligament).

These plicae meet anteriorly and form a slight transverse ridge on the poste-

rior surface of the supravaginal portion of the cervix.

Returning to the rectovaginal fascia: anteriorly it lies against and is closely ad-

herent to the posterior wall of the vagina, along the lower three-quarters or

four-fifths (approximately) of that portion of the latter which is above the uro-

genital diaphragm. At this level the rectovaginal fascia, as such, ceases but is

continued as a very thin stratum up over the upper one-fourth or one-fifth of the

vagina, then on the posterior surface of the supravaginal portion of the cervix

uteri, and then becomes part of the parametrium (see below). This thin stratumis covered by peritoneum continued up from the rectovaginal fold. Thus these

portions of cervix and vagina are covered by peritoneum. This rectovaginal

fascia is often called the perineal body because its base begins in the per-

ineum (q.v.); or the rectovaginal septum.

Without regard to the perineum, the real base of this fascia rests on the supra-

anal (deep pelvic) fascia where the latter in its turn rests on the upper layer of

the triangular ligament of the perineum and on a small area of the infra-anal

fascia. This base is much wider sagitally and transversely than the upper part,

owing to the increased distance between vagina and anal canal.

Continued forward on each side, this fascia becomes a substantial lamina in-

vesting the sides and front of the vagina, the anterior and late

supravaginal portion of the cervix, the urethra, and the bladd

the space of Retzius, as in the male.

Where it lies between bladder and cervix, just as it bends u

parametrium, this fascia is covered by the uterovesical fol

toneum forming the uterovesical pouch. The pubovesical lig

ened strands of this fascia similar to those in the male (q.v.). O

the two lateral ones are said to be continued backward to th

pubocervical ligaments. These may cause the slight ridge

seen on each side of the uterovesical pouch (uterovesical p

The lateral ligaments of the bladder, the paravesical fossae

tal fossae are the same as in the male and formed in the sam

two fossae, on each side, are separated from each other b

narrowest portion of the broad ligaments of the uterus.

These ligaments or lateral mesenteries of the uterus each

their two layers of peritoneum a thin lamina of fascia prolong

and upward (disregarding the normal anteversion of the ute

serous fascia.

The shape of this lamina is the same as that of the broad lig

borders and is now considered to be spread out flat.

(1) The lateralborder runs at first downward from a little in

iliac joint to a little behind the spine of the ischium; and then

tion of cervix with body of uterus.

(2) Theuterineborder is attached to the lateral border of th

a trifle of the same border of the cervix. From this attachme

flected right around the uterus, thus becoming the parame

ferred to, which in its turn is covered by the perimetrium (pe

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(3) The superiorborder runs along with the Fallopian tube (oviduct) and in-

vests it, covered, in its turn, of course by peritoneum.

(4) Thesuperolateralborder is comparatively short. It is curved, concavity up-

ward and outward. It extends from below the attachment to the ovary of the

ovarian fimbria to the upper end of the lateral border. At this point the ovarian

vessels enter the broad ligament. Surmounting this border is a free edge of

peritoneum (the infundibulopelvic plica or ligament). The border (fascia) itself

is the suspensory ligament of the ovary.

The uterine artery runs inward through the lower part of this intra-broad liga-

ment fascial lamina, while the ureter runs forward where this lamina comes off

from the parietal part, after hooking under the artery. The ovary receives a del-

icate prolongation from the same lamina covered by peritoneum, the meso-

varium.

Supplementary remarks. That portion of the superficial pelvic fascia between

the vagina and urethra may be called the urethrovaginal septum. Its texture is

much more delicate than that of its upward prolongation between bladder and

vagina. This septum is made up entirely, or practically so, of smooth muscle tis-

sue, according to Dr. Byron H. Goff, of New York City, who kindly showed mesome slides he had prepared of this tissue. In Dr. Goff's article, "Secondary

Reconstruction of Damaged Pelvic Floor," Surgery, Gynecology and Obstet-

rics, June, 1928, the description of the anatomy of the pelvic floor is clear and,

in the main, correct.

Exceptions. (1) Colles' fascia is not continuous with the posterior (conjoined)

margins of the triangular ligament of the perineum (q.v.) but is merely adher-

ent to them and then passes into the ischiorectal fossa. Furthermore, between

the fascia of Colles and the superficial perineal muscles is a third layer of fas-

cia (see perineum) which is continuous, over spermatic cord (external sper-

matic fascia) and penis, with the fascia between the tendon of the external

oblique and Scarpa's fascia, the latter being, as correctly stated, continuous

with that of Colles.

(2) The glands of Bartholin I have found between the layers o

ament (deep perineal interspace) and not, as stated, in the s

interspace. As homologues of Cowper's glands, they shou

situation.

The article also gives quotations from Sturmdorf and Halban

scription of the "pubic segments" of the levator ani is essen

that already given of the pubococcygeus. The rather exten

however, as to width and thickness which he gives, I have n

Halban (Operative Treatment of Female Genital Prolapses, V

ognizes, as I do, "Two distinct fasciae in the pelvis," the "mu

pelvic or supra-anal fascia) and the "fascia endopelvina" (s

serous pelvic fascia). However, he says the fascia endopelv

of a parietal and visceral portion." This statement is not in ac

description of this fascia which I have given. Nevertheless, t

ban and Tandler that the fascia endopelvina is a fascial sh

completely the uterus, bladder and rectum" is correct.

The Fascia of the Urogenital Triangle (Perineum) and Isch

These areas have been outlined and defined. Their fasciae

sidered, as a unit, disregarding partial descriptions previous

As these combined areas are the pelvic outlet their fasciae m

lectively the FASCIA of the PELVIC OUTLET.

This fascia, like that of all other regions, has a superficial

the latter, similarly to deep fascia elsewhere, characterize

subsidiary layers to enclose muscles and other higher struc

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The Deep Fascia of the Pelvic Outlet and Perineum

This comprises the infra-anal fascia and its three derivatives, viz; the fascia

between the fascia of Colles and the superficial perineal muscles, to be called

the inferior perineal fascia; and the triangular ligament (two layers) of the per-

ineum. Also that portion of the supra-anal fascia which covers the upper sur-

faces of the pubococcygeus muscles and is applied to the upper surface of

the deep layer of the triangular ligament, already described.

The infra-anal fascia: (1) The portion not covering the pubococcygeus muscle

is continued up to the white line and then downward as the obturator fascia, as

already described. Traced medially, this fascia reaches and is attached to the

medial border of the pubo-ischial ramus along which it meets the obturator fas-

cia. These two layers unite along this border and then immediately split and are

prolonged into the two layers of the triangular ligament. Thus the inferior sur-

face of the pubococcygeus muscle in the region of the perineum lies on top of

the lateral part of the deep layer of the triangular ligament which now takes

the place of the infra-anal fascia.

(2) The portion covering the pubococcygeus muscle also covers the external

sphincter ani muscle. This layer is continued forward, widening as it proceeds,until it reaches the posterior borders of the superficial transverse perinei mus-

cles. Along this line, still continuing forward, it splits into three layers: the infe-

rior perineal fascia and the two layers of the triangular ligament. There is,

however, a small shallow pocket at the extreme outer end of the sup. trans.

perin. This pocket is situated above, i.e., deep to the muscle and is formed as

follows: The infra-anal fascia proceeds to the anterior border of the trans. perin.

muscle and then is reflected back around the muscle to become the inferior

perineal fascia.

Posteriorly the infra-anal fascia is continuous with the deep fascia of the back.

The inferior perineal fascia. This is, in general, of a triangular outline, but not

so well defined as that of the triangular ligament. This fascia, in the first place,

covers the superficial (see below) perineal muscles thus form

superficial perineal pouch or interspace, of which the inferior

erroneously by most writers to be Colles' fascia.

Continued forward, i.e., from the subpubic ligament where t

region ends and the penis begins, this fascia becomes the

the tubular deep fascia of the penis and thereby is continuo

layer of the extra-abdominal fascia (q.v.; also see inferior lay

ament). Furthermore, on each side of the root of the penis t

longer to be called inferior perineal, ascends on the body o

pubic crest (lower margin of the ring) as part of the deep lay

dominal fascia, and then bends sharply downward to beco

portion of the tubular external spermatic fascia of the sper

Thus this bend of the fascia lies over or above a similar bend

under Colles' fascia (Fig. 4.)

The inferior perineal fascia traced from side to side: The late

tached to the entire medial border of the pubo-ischial ramu

the crus penis which in its turn is attached to the comparativ

of the ramus which lies between the medial and inferior bor

From this medial border the fascia is reflected around, i.e., to) the ischiocavernosus muscle and the crus and then after a

ferior border of the ramus becomes continuous with the d

thigh. This line of attachment is much firmer than that along

(Fig. 5).

On each side of the midline there is a muscular triangle forme

perficial muscles of the perineum. Thus the inferior perine

covers these muscles but also is in contact, within the confin

with the under surface of the inferior (superficial) layer of t

ment.

The superficial (so-called in all textbooks) perineal muscle

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muscles, since they lie beneath (deep to) a layer of deep fascia, i.e., the infe-

rior perineal fascia. They are collectively the lowermost or, counting from below

upward, the first muscular stratum of the perineum. The deep perineal muscles

(see below) are the second stratum; and the two pubococcygeus muscles (an-

terior portions) are the third stratum. These three strata with their fasciae con-

stitute the urogenital diaphragm (see above).

The muscles of the first stratum are: (1) bulbocavernosus, also called accel-

erator urinae (male) and sphincter vaginae (female); (2) ischiocavernosus, also

called erector penis or clitoridis; (3) superficial transverse perineal (both sexes).

Morphologically the external sphincter ani belongs to this group, but topo-

graphically it does not lie in the true perineum.

The triangular ligamentof the perineum. As already stated this ligament con-

sists of two layers of fascia, the inferior or superficial and the superior or deep.

The space between them is known as the deep perineal pouch or interspace.

Posteriorly these layers are united because they, together with the inferior per-

ineal fascia, are simply splits of the infra-anal fascia, already described.

Laterally these layers join together along, and are attached to, the medial bor-

ders of the pubo-ischial rami each of which begins at the front of the ischialtuberosity (which is the meeting place of crus penis, ischio-cavernous and

trans, perin. muscles) and extends to the subpubic ligament (inferior border of

symphysis).

At this point, traced forward (or upward), the two layers separate: Th e inferior

layer passes in front of the extreme lower part of the symphysis just deep to

where the corpus spongiosum (cavernous urethrae) unites with the corpora

cavernosa, and then blends, around the upper ends of the bulbocavernosus

and ischiocavernosus muscles, with the inferior perineal fascia to form or be-

come the posterolateral segment of the deep fascia of the penis.

The superior layer passes behind the symphysis and at about the level of the

two pubic points (see above) blends with the deep pelvic or

to become the transversalis fascia (Fig. 4).

Just below the subpubic (arcuate) ligament the deep dorsa

(clitoris) pierces both layers of the triangular ligament and is

very delicate fibers from each layer. These fibers have be

what unnecessarily (?) the "transverse pelvic ligament."

Among other structures found between the se layers of the t

are: (1) The deep perineal muscles; (2) urethra (male); (3) u

(female); (4) bulbo-urethral glands (Cowper's, male); (5)

(Bartholin's, female).

Each of these layers blends with the wall of urethra (both s

where it is pierced by these structures.

The deep perineal muscles. These are: (1) the variously ca

constrictor, sphincter urethrae (male); urogenital sphincter

the deep transverse perineal (both sexes).

Laterally these muscles (frequently (2) is simply the back ba very thin edge which is tucked in between the lateral attac

ers of the triangular ligament. Medially these muscles are a

hind forward, to the central tendinous point of the perineum

see below); the vagina (female) and urethra (both sexes)

membranous portions of these tubes.

The perineal center. This is an area of fused planes of fasci

uated in the male, between the anus and bulb of the corpus s

female, between the anus and vagina. The extent, approxim

in all directions is male, half an inch; female, one inch more

ures are given in the textbooks. The planes of fascia, the fus

this area, are, from below upward: (1) inferior perineal fasc

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of the triangular ligament i.e., the midpoint of the line of splitting of the infra-anal

fascia, of which a small portion may share in the fusion; and (3) the supra-anal

fascia.

To this perineal center are attached fibers of all the perineal muscles both su-

perficial and deep, including the ext. sphinct. ani, except the ischiocavernosus.

In the female the area of the center included within the attached fibers of all

these muscles is much more extensive than in the male. In the latter these

fibers are very close together so much so that the "center" is often called the

"point."

Resting on and closely adherent to the upper surface of the supra-anal fascial

portion of the center is the base of the rectovaginal septum, also known as the

perineal body (see above.) In the male, similarly, is attached the base of the

rectoprostatic and rectovesical fascia (q.v.), rarely spoken of as the "perineal

body." The dimensions of this lamina of fascia, except perhaps from side to

side, are considerably less than those of the rectovaginal septum. It is also

less substantial than the latter.

Colles' fascia (see below) is fairly well adherent to the center. Very frequentlythe skin area corresponding to the region between anus and vagina is called

the perineum.

Returning to the medial border of the puboischial ramus: along this entire bor-

der we find attached the following planes or layers of deep fascia: (1) inferior

perineal fascia; (2) inferior layer of triangular ligament; (3) superior layer of tri-

angular ligament; (4) infra-anal fascia; and (5) obturator fascia. The supra-anal

fascia is not attached to this border because it is shifted away from it, so to

speak, by the interposition of the lev. ani, where this muscle, considered as a

sheet, curves medially to become the pubococcygeus, which now comes to

lie between the superior layer of the triangular ligament below and the supra-

anal fascia above (Fig. 5).

Thus the two pubococcygeus muscles, from a perineal point

a third muscular stratum, considering always the medial fre

and the intervening supra-anal fascia (previously described

The Superficial Perineal Fascia

This is continuous with the superficial extra-abdominal fascia

be split into two layers: the superficial, which has no name

sponds to Camper's fascia; and the deep layer, known as C

which corresponds to Scarpa's fascia.

Fascia of Colles. This covers, i.e., lies below or superficial t

ineal fascia, and has the same lateral atta

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Planes of Fascia

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